TEST BANK FOR Health Assessment for Nursing Practice 8th Edition by Susan Fickertt Wilson PhD RN (Author), Jean Foret Giddens PhD RN FAAN ANEF (Author) ISBN978-0443124433 COMPLETE GUIDE WITH RATIONALES 100% VERIFIED A+ GRADE ASSURED!!!!NEW LATEST UPDATE!!

,Chapter 01: Introduction to Health Assessment
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Wilson: Health Assessment for Nursing Practice, 8th Edition
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MULTIPLE CHOICE wx




1. A patient comes to the emergency department and tells the triage nurse that he is ―havi
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ng a heart attack.‖ What is the nurse‘s top priority at this time?
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a. Determine the patient‘s personal data and insurance coverage.
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b. Ask the patient to take a seat in the waiting room until his name is called.
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c. Request that a nurse collect data for a comprehensive history.
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d. Ask a nurse to start a focused assessment of this patient now.
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ANS: D w x


The nurse needs to begin an assessment as soon as possible that is focused on this patie
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nt‘s cardiovascular system. The type of health assessment performed by the nurse is also
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driven by patient need. Personal data and insurance information will be obtained, but in t
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his situation, these data can wait until after the patient is assessed. Based also on Maslo
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w‘s hierarchy of needs, physiologic needs take precedence. Rather than asking the patient
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to wait, the nurse needs to begin data collection, such as vital signs, immediately to det
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ermine the patient‘s health status. Complications can be prevented if an immediate assess
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ment is made to analyze the patient‘s symptoms. A comprehensive history is not indicate
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d in this situation at this time. Some subjective data will be collected, such as allergies a
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nd medical history related to cardiovascular disease. Eyes, ears, or a complete musculosk
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eletal or mental health assessment is not a priority at this time.
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DIF:Cognitive Level: Apply REF: Box 1- wx wx w x wx


3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establ
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ishing Priorities wx




2. Which situation illustrates a screening assessment?
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a. A patient visits an obstetric clinic for the first time and the nurse condu
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cts a detailed history and physical examination.
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b. A hospital sponsors a health fair at a local mall and provides cholesterol and
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blood pressure checks to mall patrons.
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c. The nurse in an urgent care center checks the vital signs of a patient w
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ho is complaining of leg pain.
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d. A patient newly diagnosed with diabetes mellitus comes to test his fasting b
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lood glucose level. wx wx




ANS: B w x


A health fair at a local mall that provides cholesterol and blood pressure checks is an ex
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ample of a screening assessment focused on disease detection. A detailed history and ph
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ysical examination conducted during a first-
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time visit to an obstetric clinic is an example of a comprehensive assessment. Assessing
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a patient complaining of leg pain in the triage area of an urgent care center is an examp
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le of a problem-
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based/focused assessment. A patient‘s return appointment 1 month after today‘s office vis
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it to report fasting blood glucose levels is an example of an episodic or follow-
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up assessment.
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DIF:Cognitive Level: Understand wx wx REF: Box 1-3 wx wx

, TOP:Nursing Process: Assessment wx wx


MSC:NCLEX Patient Needs: Health Promotion and Maintenance: Health Screening
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3. For which person is a screening assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
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d. The person who is beginning rehabilitation after a knee replacement
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ANS: B wx


A screening assessment is performed for the purpose of disease detection. In this case thi
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s person may have diabetes mellitus. A shift assessment is most appropriate for the perso
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n who is recovering in the hospital from surgery. A comprehensive assessment is perfor
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med during admission to a facility to obtain a detailed history and complete physical exa
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mination. An episodic or follow- wx wx wx wx


up assessment is performed after knee replacement to evaluate the outcome of the proced
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ure.

DIF:Cognitive Level: Understand REF: Box 1- wx wx wx wx


3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establ
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ishing Priorities wx




4. For which person is a shift assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
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d. The person who is beginning rehabilitation after a knee replacement
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ANS: A wx


A shift assessment is most appropriate for the person who is recovering in the hospital fr
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om surgery. A screening assessment is performed for the purpose of disease detection, in t
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his case diabetes mellitus. A comprehensive assessment is performed during admission to
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a facility to obtain a detailed history and complete physical examination. An episodic or f
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ollow-
up assessment is performed after knee replacement to evaluate the outcome of the proced
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ure.

DIF:Cognitive Level: Understand REF: Box 1- wx wx wx wx


3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establ
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ishing Priorities wx




5. For which person is a comprehensive assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
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d. The person who is beginning rehabilitation after a knee replacement
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ANS: C wx


A comprehensive assessment is performed during admission to a facility to obtain a detai
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led history and complete physical examination. A shift assessment is most appropriate fo
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r the person who is recovering in the hospital from surgery. A screening assessment is p
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erformed for the purpose of disease detection, in this case diabetes mellitus. An episodic
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or follow-
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up assessment is performed after knee replacement to evaluate the outcome of the proce
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dure.

, DIF:Cognitive Level: Understand REF: Box 1- wx wx wx wx


3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establ
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ishing Priorities wx




6. For which person is an episodic or follow-up assessment indicated?
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a. The person who had abdominal surgery yesterday
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b. The person who is unaware of his high serum glucose levels
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c. The person who is being admitted to a long-term care facility
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d. The person who is beginning rehabilitation after a knee replacement
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ANS: D wx


An episodic or follow-
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up assessment is performed after the knee replacement to evaluate the outcome of the pr
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ocedure. A shift assessment is most appropriate for the person who is recovering in the
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hospital from surgery. A screening assessment is performed for the purpose of disease de
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tection, in this case diabetes mellitus. A comprehensive assessment is performed during a
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dmission to a facility to obtain a detailed history and complete physical examination.
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DIF:Cognitive Level: Understand REF: Box 1- wx wx wx wx


3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Safe and Effective Care Environment: Management of Care: Establ
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ishing Priorities wx




7. Which is an example of data a nurse collects during a physical examination?
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a. The patient‘s lack of hair and shiny skin over both shins
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b. The patient‘s stated concern about lack of money for prescriptions
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c. The patient‘s complaints of tingling sensations in the feet
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d. The patient‘s mother‘s statements that the patient is very nervous lately
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ANS: A wx


The lack of hair and shiny skin over both shins are objective data or signs that are part
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xof the physical examination. A patient‘s concerns about lack of money are subjective da
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ta and are part of the health history. A patient‘s complaints of tingling sensations in the
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xfeet are subjective data and are part of the health history. A patient‘s family statements
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are considered secondary data, are subjective data, and are part of the health history.
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DIF:Cognitive Level: Apply REF: Box 1- wx wx w x wx


3 TOP:Nursing Process: Assessment
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MSC:NCLEX Patient Needs: Physiological Integrity: Reduction of Risk Potential: System Specif
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ic Assessments
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8. The nurse documents which information in the patient‘s history?
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a. The patient‘s skin feels warm to the touch.
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b. The patient is scratching his arm.
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c. The patient‘s temperature is 100 F.
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d. The patient complains of itching.
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ANS: D wx